We welcome this clarity on exceptions

This is a level of detail that has previously existed only for practices in Scotland. Exceptions are the most controversial area of the quality and outcomes framework and understanding their patterns is important.

The figures that have come from the Information Centre, via HSJ, do not give breakdowns on the reasons for patients being exception reported. These details are available on the quality management and analysis system at practice and primary care trust level, and allow some of the underlying factors to be identified.

Patients are automatically excepted for three to nine months after joining a practice. Those with fast-growing list sizes have been excluded from HSJ's tables, but those with rapid list turnover have not. A breakdown of the figures could show how many patients were automatically excepted due to the date of their registration and how many were coded as informed dissent by practices. We could see how many patients were considered to be having the maximum treatment appropriate.

Even with this level of information, it would be impossible to say which practices were "right" and which were "wrong". Exception reporting is something that is done out of necessity rather than routinely. If a target looks likely to be missed, then exceptions are looked for more carefully. In fact, many more patients could be excepted than is actually the case.

It is also probably incorrect to believe that coded exceptions are entirely down to the practice. In many cases it is not that the practice has "given up" on the patient, but rather that the patient has given up on medical care. Motivation is at the root of many of our health inequalities.

Similarly, secondary care services can strongly affect practice figures. As an example, the indicator CHD 2 has a wide range of exception rates, from zero to 100 per cent, but is dependent on provision of exercise testing by secondary care.

Dr Gavin Jamie, editor, www.gpcontract.co.uk